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BUILDING- INSPECTOR RECORD SITE.WORK DATE ID/S!G.COMMENTS OWNIiR BI,ILDER DIiLCARATION r' ' I hereby affirm under penalty of perjury that I am exempt from the Contractors' Licensc l-aw for the following rcason (Sec.7031.5 lJusiness and Prolbssion Code): Any City or County which requires a Jrermit to conslrucl. aller. improve. demolish or repair any structure. prior to its issuance. also requires the applicant for such pernrit to file a signed slaternenl that hc or shc is licenscd pursuant to thc. provisions of the Contractor's l,icensed Iaw (Chapter 9, Commencing with Scction 7fiX) ol' l)ivision 3 of the Bu.siness and Prof'essions Code) or that hc or she is exempt therefrom and the basis tbr the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects thc applicant to a civilpcnaltyof not more than five hundred dollars ($stXl;. _1, a.s owncr ol'thc propcrly, or my employces with wages as lheir sole compcnsation, will do the work and thc structure ls rnt interxlctl or offered for sale (Scc'.70+1. Busincss and Pnrfessions Crxle: The Contractor's Liccnsc Law rlocs nol apply to an owner of the propcrly who builds or improves thereorl arxJ who tkxs such work himself or herself or through his or her own employecs, provided that such improverrcnts are not intended or oll'ered for sab. Il. however, thc building or improvcnrcnt is sold within one year of conqrhtion, the Owner Builder will have thc burden of pnrving that lrc or she did not build or improve tlrc propcrty for tlr purposc of sale). _1, as owner of the property, am exclusively contracting with licen.sed conlraclors to construct thc project (Scc. 7(X4, Business and hotbssionCode: TheContractor'sLicenseLawdoesnotapplytoanownerofpropertywhobuildsorimproveslhereon. and who contracts lor such pnriccls with a Contraclor(s) liccnscd pursuanl to lhc Contraclor's License Law). _l am exempt under Section_, B. & P.C. tbr this reason. Dale: W( )RK I.IRS' C( )Nl PENSA'I ION DI.]CLARATI0N I hcre'by alllrm undcr pcnalty of pcrjury onc ol'thc t'olkrwing dcclarations: _l have and will maintain a Certilicatc of Consent to Self-lnsure frlr workers' compensation, as provided for by Scction 3700 of the Labor Code, for the Jrcrformance of thc work lbr which thc Jrcrmit is lssued. _l have and will maintain workers' conrpensation insurance, as required by Section 3700 of thc Labor Code, for thc pcrfornrarre of tlrc work tbr which this Jrcrmit is issuctl. My workcrs' compcnsation insurance carricr arxl gxllicy nurnbcr arc: Policy Nurnbcr: Expires: _l ccrtity that in the pcrtbrnrance of thc work firr which this pcrndt is issued, I shall not employ any pcrson in any nunncr so as to become suhjcct to thc workers' conrpcrrsation laws of California, and agree that if I should bccome subjcct to thc workers' conllrcnsation provisions of Section 3700 of the Labor Code, I shall, forthwith conrply with thosc provisions. WARNING: Failure to secure workers'compcnsation covcrugc is unlawful, and shall suhject an cmploycr to criminal Jrcnaltics civil fines up to one hundred thousand dollars ($l(X),(Xru). in addition to lhe cost of conrpensation, damages as providcd for Section 1076 of the Latxrr Cbde, interesl and allorney's fees. and the a LICENSED CONTRACTOR DECLARATION I hereby aflirm undcr penalty of perjury that I am licensed under provision of Chaptcr 9 (cornnrncing with Scction 7000) ol'Division 3 o of the Business and Prcfessions Codc, tuxl my license is in full tbrce and effect. License Class: License Number: CON.STR('CTION I,ENDING AGF:NCY I hercby atlirm under Jrenalty of perjury that therc is a construction lendfurg ager&-y for the performance of the work lbr which this permit is issued (Scc. 3097, Civ. C.). lrnder's Name: hnrtcr's Address: APPLICANT DECLARATION I hereby affrm under penalty of perjury one of the ftrllowirrg declaralions: Demolition Permits-Asbestos Notification Federal Regulations (Title 40, Part6) _Required l-etter of Notification _l certi$ that the federal regulatioru rcgarding asbestos removal are not applicable to this project. _l certify that I have read this application arxl statc that thc abovc information is corrccl. I agroc to comply with all City and County onlfurances and State l-aws relating to building constnrctiorl aill hcreby authorize representativcs of this City and County to enter upon thc above rnentioned propcrly for inspction purfxJses. Applicant or Agent Permitee name (prlnf): Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Su bf loor/Ve nVI n s u I atio n Roof Sheathinq Shear Wall Framing Insulation/Energy Drywall Ext./lnt. Lath Brown Coat J\Iason ry Pool Fence T-Bar Handicap Req Deoutv Final Report Enoineer Final Report Flood Zone Certif FINAL Certificate of Occupancv Notes, Remarks, Etc. L !